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Pre-Hospital Assessment Sheet: Triage Score

This pre-hospital assessment sheet is used to document medical information and treatment for a patient. It includes sections to record the patient's presenting problem, allergies, medical history, injuries, vital signs, level of consciousness, treatment provided, and discharge information. The sheet provides a standardized way for emergency responders to assess, track, and communicate a patient's condition and care.

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ratna purwitasari
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1K views2 pages

Pre-Hospital Assessment Sheet: Triage Score

This pre-hospital assessment sheet is used to document medical information and treatment for a patient. It includes sections to record the patient's presenting problem, allergies, medical history, injuries, vital signs, level of consciousness, treatment provided, and discharge information. The sheet provides a standardized way for emergency responders to assess, track, and communicate a patient's condition and care.

Uploaded by

ratna purwitasari
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Triage Score

Pre-Hospital
12345 Assessment Sheet
Date: Time in: Patient Name: Age: Sex:

Presenting Problem:

Allergies: Medications:

Medical History
⃝ None Known ⃝ Asthma ⃝ Diabetes ⃝ Epilepsy
⃝ Not Available ⃝ Cardiac ⃝ Hypertension ⃝ Medi Alert
⃝ Anti-Depressants (Used Recently ⃝ Yes / ⃝ No) ⃝ Other
Mark injuries on the diagram using the legend
Airway Normal Abnormal
A Abrasion
Bl Bleeding
Breathing Normal Abnormal
Bu Burns
C Contusion
Pulse Normal Abnormal
D Deformity
F Fracture
Perfusion Normal Abnormal
L Laceration
P Pain
Pt Aggressive / Agitated No Yes
S Swelling
T Tenderness
BSL mmol/L

AVPU / Pupil Pupil Pupil Pulse Resp Rate Pain


Time BP Temp SpO2
GCS L Size R Size Reactive per minute per minute Score
Recommended clinical criteria to trigger immediate senior clinician review
< 100 or < 35.5 C
Any decrease in level of consciousness < 50 < 12 < 95% on
> 140 or
or new confusion or > 100 or > 22 Room Air
systolic > 38 C

Eye opening Response Verbal Response Motor Response


4 - Spontaneous 5 - Orientated 6 – Obeys Commands
3 - To Sound 4 - Confused 5 – Purposeful movement to stimuli
2 - To pain (not to face) 3 – Inappropriate Words 4 – Withdraws to pain
1 - No Response 2 – Incomprehensible Speech 3 – Flexion
1 – No Response 2 – Extension
1 – No Response
This template was developed by Mardi Gras Medical and is being used with their permission with thanks
Treatment Provided
Medication / Fluids / O2 / Given by
Time Dose Route Response
Intervention Sign & Print

Comments:

Discharged: ⃝ Returned to Event ⃝ Leaving the Venue ⃝ Ambulance (Car #_______)


Patient Friend / Contact Name: Contact Phone Number:

Time Discharged from Medical: Treatment completed by:


Case Discussed with: (Sign and Print name)
SHPN (CPH) 190492

This template was developed by Mardi Gras Medical and is being used with their permission with thanks

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